Nectozing scleritis

1. 238 © 2021 Middle East African Journal of Ophthalmology | Published by Wolters Kluwer - Medknow
Superficial Temporal Muscle Fascia
Grafting: Successful Transplant of
Surgical‑induced Necrotizing Scleritis
Hsouna M. Zgolli, Sonya Mabrouk, Olfa fekih, Ines Malek, Leila Nacef
Abstract:
To report the case of a surgical‑induced necrotizing scleritis (SINS) following vitreoretinal surgery for
rhegmatogenous retinal detachment, successfully managed by superficial muscle temporal fascia
grafting. An 18‑year‑old teenager, with a history of a 23G vitrectomy with silicone oil tamponade for
rhegmatogenous retinal detachment of the left eye, presented with intense left ocular pain, decreased
visual acuity to counting fingers and eye redness. Split lamp examination showed: Conjunctival
infiltration with silicone oil, circumferential sclera thinning with ectasia of the underling uvea. The
fundus examination showed an attached retina. Necrotizing scleritis was the retained diagnosis. SINS
was the final diagnosis. An immunosuppressive therapy was started. Superficial muscle temporal
fascia grafting was performed to cover the necrotizing sclera. The patient did well postoperatively
without sclera thinning or ectasia and the fascia grafting still intact without retraction after 6 months
of follow‑up. This is the first case in the literature that used the superficial temporal muscle fascia as
a graft for sclera reinforcement in SINS. We propose new support to reinforce the deficient sclera.
This graft must be associated with prompt immunosuppressive therapy at high doses.
Keywords:
Graft, necrotizing scleritis, superficial temporal muscle, surgery induced, transplantation
Introduction
Su r g i c a l ‑ i n d u c e d n e c r o t i z i n g
scleritis (SINS) is a rare and severe
form of scleritis.[1]
It’s a postoperative
complication reported after ocular surgery
including cataract surgery, trabeculectomy,
pterygium’s excision, penetrating
keratoplasty, and pars plana vitrectomy.[2]
The exact pathogenesis of this disease
is not yet fully understood nevertheless
most likely theory is the immunological
mechanism.[3]
Immunosuppressive therapy is the most
successful and tolerated treatment.[2‑4]
However, this therapy especially in
extended SINS can be insufficient to control
the progression’s process. To the best of
our knowledge, the present case is the
first one in the literature reporting SINS
management by superficial muscle temporal
fascia grafting.
Case Report
This case report was carried out in
accordance with the principles of the
Declaration of Helsinki and was approved
by the Ethics Committee of Institute Hedi
Raies of ophthalmology.
A verbal and written consent was provided
by the patient for the publication of personal
medical information and images.
An 18‑year‑old teenage, with myopia
history, underwent a 23G pars plana
vitrectomy with silicone oil tamponade for
Address for
correspondence:
Dr. Sonya Mabrouk,
Institute Hedi Raies
of Ophthalmology,
Tunis, Tunisia.
E‑mail: mabrouksonya@
yahoo.fr
Received : 02‑11‑2020
Revised: 10-12-2020
Accepted: 29‑12‑2020
Published: 19-01-2021
Institute Hedi Raies of
Ophthalmology, Tunis,
Tunisia
Case Report
Access this article online
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Website:
www.meajo.org
DOI:
10.4103/meajo.
MEAJO_380_20
How to cite this article: Zgolli HM, Mabrouk S,
fekih O, Malek I, Nacef L. Superficial temporal
muscle fascia grafting: Successful transplant
of surgical-induced necrotizing scleritis. Middle East
Afr J Ophthalmol 2020;27:238-40.
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2. Figure 2: Postoperative photograph: successful reconstruction of ocular integrity at
3 months after surgery
Figure 1: Preoperative photograph: and surgical procedure. (a) scleral defect with
ectasia of the underling uvea. (b) ectasia of the uvea after conjunctival dissection:
there is a larger defect of sclera than expected preoperatively. (c) The autogenous
aponeurosis’s temporal muscle was transplanted over the sclera defect with
interrupted 10‑0 nylon sutures
c
b
a
Zgolli, et al.: Successful transplant of surgical‑induced necrotizing scleritis
Middle East African Journal of Ophthalmology ‑ Volume 27, Issue 4, October-December 2020 239
rhematogenous retinal detachment of the left eye. Laser
retinopexy of peripheral tears was intraoperatively
conducted without cryotherapy. Two months later, the
patient has suffered intense left ocular pain, decreased
visual acuity, and eye redness. Visual acuity was
decreased to counting fingers. Split lamp examination
showed: conjunctival infiltration with silicone oil, a
circumferential scleral thinning, predominant in superior
nasal and ectasia of the underling uvea [Figure 1a]. The
cornea was transparent, the photo motor reflex was
normalwithphacosclerosis.Fundusexaminationshowed
an attached retina, documented by the echography B.
In front of these signs, a necrotizing scleritis was
the first evoked diagnosis. Postoperative infective
scleritis was ruled out with negative microbiological
assessment of scleral scrapping. Blood tests including
serologies (syphilis, tuberculosis, herpes, toxoplasmosis),
full blood count, erythrocyte sedimentation rate,
C‑reactive protein, rheumatoid factor, antinuclear
antibody, and anti‑neutrophil cytoplasmic antibody tests
were performed.[3]
A general physical examination was also performed.
Results were negative for both systemic vasculitis and
arthritis. An orbit cerebral magnetic resonance imaging
was performed eliminating the ocular or cerebral tumor.
Considering these findings, SINS was the final diagnosis.
An immunosuppressive therapy based on general
corticotherapy (prednisone 1 mg/kg) was started
associated with topical corticosteroids. Owing to
impending risk of globe perforation, superficial muscle
temporal fascia grafting was performed wrapping the
necrotizing sclera [Figure 1b and c].Oral azathioprine
(2.5 mg/kg during the first month) was started
postoperatively in addition to corticosteroids with
progressive decrease for both immunosuppressive
therapies. The patient did well where the fascia
grafting is still intact without retraction or rejection for
6 months [Figure 2].
Surgical technique
A 360° anterior conjunctival dissection was performed.
We evacuated the silicone in subconjunctival. Exploration
has revealed significant 360° scleral thinning, greater in
superior nasal without obvious perforation [Figure 1b].
We measured the area of prolapse. Patches of the fascia
of the superficial temporal muscle were cut and modeled
according to the air of sclera prolapsed [Figure 1c]. The
different patches had variable surfaces that were larger
than the areas of the scleral defect (>1 mm minimum).
The suture of the patches was performed as follows:
4 separate cardinal sutures under tension, with a 10‑0
monofilament, then a 360° overlock of each patch with a
6‑0 vicryl yarn [Figure 1c]. We ended with a conjunctival
closure on 360° by separated sutures by vicryl 7‑0.
Discussion
SINS are a severe form of scleritis and a threat to
globe integrity.[1]
It requires prompt and aggressive
immunosuppressive therapy after ruling out infectious
etiology.[1,2]
Many studies involved hypersensitivity response
as the major mechanism of triggering SINS.
Therefore, their therapeutic approach was based on
immunosuppressive molecules.[2,3]
Corticoids with high
doses, cyclophosphamide, and azathioprine are the main
immunosuppressive drugs used to control and stop SINS
progression.[1‑3]
In severe cases, in addition to immunosuppressive
therapy, damaged tissue surgical replacement is
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3. Zgolli, et al.: Successful transplant of surgical‑induced necrotizing scleritis
240 Middle East African Journal of Ophthalmology ‑ Volume 27, Issue 4, October-December 2020
required. The SINS surgical management is still
challenging. Multiple material grafts have been used for
patch grafting: amniotic membrane, pericardium, fascia
lata, and Gore‑Tex (synthetic material).[1,5]
The amniotic membrane is widely used for ocular
surface reconstruction, especially in necrotizing scleritis
with uveal ectasia. In fact, it is available, nonantigenic
and without a risk of immune rejection. Furthermore,
the amniotic membrane has many growth factors,
stimulates reepithelialization and reduces fibrosis and
inflammatory reactions.[6]
Similarly, the fascia lata grafting shows promising results,
especiallyintheextendedareaofnecrosis.Kobtanreported
a special case of SINS in a traumatic eye with multiple
surgical interventions and multiple sclera damages. The
fascialatacoveredallthenecrotizingareaandprovidedthe
tectonic integrity of the globe.[1]
The fascia lata is relatively
acellular,durable,withnoriskoftissuereactionorrejection
and without risk of potential disease transmission.[1]
To our knowledge, our case is unique in literature: It’s
the first case in the literature that used the superficial
temporal muscle fascia as a graft for sclera reinforcement.
We chose this tissue for several reasons: homograft
technique, availability, acellular, sustainability, very
strong and with large size. It successfully covered the
hole ectasia, over 360°.
The inclusion of immunosuppressive therapy
immediately on postoperative is crucial to avoid
rejection and necrosis of the graft.[7]
In our case, the
corticoids were administrated, with high doses before
the surgery. Azathioprine was immediately prescribed
postoperatively in association to oral corticotherapy to
increase graft survival.
In conclusion, SINS is a rare complication after pars plana
vitrectomy with challenging management. Different
approaches are proposed to control necrotizing extension
and preserve globe integrity. Surgical management and
aggressive immunotherapy are usually necessary in
order to get successful results. In our case, we offer a new
support to reinforce the deficient sclera and reduce the
uveal prolapse: the superficial temporal muscle fascia
providing good tectonic support for the globe. This graft
must be associated with prompt immunosuppressive
therapy at high doses.
Declaration of patient consent
Theauthorscertifythattheyhaveobtainedallappropriate
patient consent forms. In the form, the patient (s) has/
have given his/her/their consent for his/her/their
images and other clinical information to be reported in
the journal. The patients understand that their names
and initials will not be published and due efforts will
be made to conceal their identity, but anonymity cannot
be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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tectonic support in surgically inducednecrotizing scleritis.
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2. Morley AM, Pavesio C. Surgically induced necrotising scleritis
following three‑port pars plana vitrectomy without scleral
buckling: A series of three cases. Eye (Lond) 2008;22:162‑4.
3. Das S, Saurabh K, Biswas J. Postoperative necrotizing scleritis:
A report of four cases. Middle East Afr J Ophthalmol 2014;21:350‑3.
4. Vagefi MR, Hollander DA, Seitzman GD, Margolis TP.
Bilateral surgically induced necrotising scleritis with secondary
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5. Zheng X, Kodama T, Goto T, Ohashi Y. Autologous fascia lata
grafts for scleral repair in eyes with infectious necrotizing scleritis.
Arch Ophthalmol 2011;129:1225‑7.
6. Karalezli A, Kucukerdonmez C, Borazan M, Akova YA. Successful
treatment of necrotizing scleritis after conjunctival autografting
for pterygium with amniotic membrane transplantation. Orbit
2010;29:88‑90.
7. Wen JC, Lam J, Banitt MR. Scleral patch graft with a suture
reinforcement technique in surgical management of necrostizing
scleritis With ectasia. Cornsea 2018;37:933‑5.
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